Philippe Couturier

Médecins Sans Frontières (MSF) is the world’s leading independent humanitarian organisation for medical aid. Annually, some 3,000 volunteer doctors, nurses and support staff work in trouble spots around the world helping those living on the edge of human tolerance.

Médecins Sans Frontières teams are currently in 70 countries, working with more than 15,000 locally recruited staff in conditions that are always challenging, sometimes dangerous.

Médecins Sans Frontières was formed in 1971 by a group of French doctors who had previously worked with famine victims in Biafra. All were frustrated by the bureaucracy they encountered and by the degree of governmant interference in government aid.

Médecins Sans Frontières is now an international movement with a network of sections in 18 countries. Their teams are made up of people with backgrounds that include everything from: medicine, nursing, logistics, engineering and administration – all skills essential in restoring health care to communities torn apart by natural disasters, epidemics, famine, or civil war.

CLW's Interview with Philippe Couturier

As Head of Medecins Sans Frontieres Australia, what does your position involve? What attracted you to this position?

My position as Executive Director of MSF in Australia involves daily activities and also looking at the long-term strategy for MSF in Australia.

On the daily management side, the office in Sydney is involved in recruitment of field volunteers drawn from the Australian and New Zealand medical profession.

We are now 11 -years-old in Australia and we have enjoyed making significant contributions to humanitarian operations around the world. In that time we have sent Australians and New Zealanders on more than 600 missions around the world, quite often into conflict zones such as Afghanistan, Sudan, Iraq and the Democratic Republic of Congo, which is now experiencing a terrible crisis after years of civil war.

We are also doing some external communications informing the public and the media about issues to do with MSF operations in the field.

In the long-term strategy, we are now working on how best we can add-value to the operations in the field and considering some interesting developments in the field of MSF’s HIV/AIDS and TB projects, especially the treatment of children with regard to these diseases. Our office in Sydney is now playing a central role in this issue by having a paediatrician being the medical advisor for all MSF projects with a specific focus in the Southeast Asian region.

Long-term means also being able to forecast the needs in term of money, as you may know 80% of the MSF projects are financed by private donations, this allows us to keep our independency from any political agenda.

As a humanitarian medical aid organisation, our charter gives us the mandate to assist populations in need or at risk from conflict or disaster situations irrespective of race, religion or political conviction. We work in nearly 75 countries worldwide. More than 30 % per cent of our activities are in armed conflict situations where only our neutrality, impartiality and independence of political affiliation has enabled us to reach those who are most vulnerable and in need of humanitarian assistance.

Maintaining this independency is crucial for MSF especially in an era in which there is a growing confusion, internationally, between humanitarian and military roles of operation, MSF Australia has decided to increase its fundraising activity in order to be able to strongly contribute financially to this goal. This is part of our responsibility and I’d like to use this opportunity to thank the Australian public for its on going support.

All these different aspects and activities make my job very exciting but also very challenging as well.

What is the scale of operations in the Australian division of Medecins Sans Frontieres? How is the Australian branch linked to the international headquarters of Medecins Sans Frontieres?

Médecins Sans Frontières is composed by 19 sections, five of which are what we call Operational Centres (France, Belgium , Holland , Switzerland and Spain ), who are directly in charge of our field operations. The 14 other sections are what we call Partner Sections, like MSF Australia. All together, we contribute with human resources (field volunteers), finance and by communicating on more than 480 (in 2002) projects that MSF is running in more than 75 countries. In order to have some coherence and common policies, we have the International Council (IC) that is composed by the presidents of the 19 sections and they meet two or three times a year. But to ensure the smooth operation of the various issues we have to deal with, the IC has an office in Geneva which is led by MSF International President, Dr Rowan Gillies - a doctor from Sydney who is also the President of our section here in Australia- and Marine Buissioniere is the general secretary of MSF International. Both with a group of coordinators address the executives and presidents of all the section-issues and challenges that our organisation is confronted with.

On a more practical point of view, MSF Australia belongs to a group within the international network – the MSF France Group - that is composed by MSF France, USA , Japan and Australia . In this group we work and share together the responsibilities and promotion of our field activities. For doing so, we have currently about 25 staff in total and more than 15 office volunteers in our Sydney office. As an example, last year we sent volunteers on 115 humanitarian missions overseas and supported projects in nine different countries amounting to AUD$5.8 million, going directly to our life-saving work in: Afghanistan, Burma, Cambodia, China, Darfur, Kenya, Laos and Thailand.

Since January 2005, our section is in charge of providing medical advice on the paediatric domain of our projects within the MSF France Group, with a special focus on HIV/AIDS and TB.

Does MSF recruit medical and non-medical staff aside from those who volunteer their services? What are the volunteers offered in terms of remuneration etc? How many staff are currently medical and non-medical volunteers working for MSF Australia ?

On average MSF Australia continuously has around 70 volunteers working in the field.

Volunteers leaving to field missions are given a stipend of approximately $1000 per month to help individuals to keep their financial commitments while being away. Aside of this amount all transport, accommodation and living expenses are covered by MSF.

How are MSF staff prepared for working in the frontlines so that they are able to cope with all types of crisis?

To help volunteers face the main aspects and contexts in which the organisation works, MSF has a number of training and preparation courses organised each year. Before sending volunteers on their first mission we offer most of them a three-day preparation course called Welcome Days. At a later stage, we also organise and offer a number of other specific training courses covering the multiple and complex aspects encountered by volunteers at field level (administration, management, logistics, specific medical courses, etc.). In Australia we also offer to our experienced volunteers opportunities to attend Refugee Health courses (with James Cook University in Townsville and with the MacFarlane Burnet Institute in Melbourne ).

Our recruitment process and criteria focuses strongly in selecting applicants that have the appropriate experience and skills needed to face the difficult contexts in which MSF works. In the field itself, MSF tries to keep a strict balance between experienced volunteers and first mission volunteers to provide those with less experience with the most appropriate and best support possible. After every mission, MSF Australia’s Psychosocial Support Network assistance is offered and available to all returned volunteers.

Where does MSF obtain aid and funding from? What does MSF do when the supplies reach critically low levels and funding is difficult to obtain?

Internationally, MSF receives about 80% of its funding from private donations and about 20% from institutional and other donors. In 2003 (figure 2004 not available yet) we had 2.6 million individual donors worldwide supporting our projects.

Private donations are crucial for Médecins Sans Frontières . As a humanitarian medical aid organisation, our charter gives us the mandate to assist populations in need or at risk from conflict or disaster situations irrespective of race, religion or political conviction.

As I said earlier, more than 30 % per cent of our activities are in armed conflict situations where only our neutrality, impartiality and independence of political affiliation has enabled us to reach those who are most vulnerable and in need of humanitarian assistance. In an era in which there is a growing confusion, internationally, between humanitarian and military operation, there are clear risks associated in being seen as a provider of services for governments involved in a conflict. The only acceptable option for us is to have the financial capacity to provide humanitarian assistance to the victims of conflicts or natural disasters with full and complete financial and political independence.

To guarantee this capacity and to prevent funding difficulties, we ask our donors to become ‘Field Partners’. This means for them to financially support our projects on a monthly basis with an amount of money they decide to contribute. This allow us to better plan what we are be able to achieve in a year’s time but most of all, this helps us to provide medical and humanitarian assistance with little or no delay, especially in the case of emergencies such as the Asian Tsunami recently.

In which countries is MSF currently involved? How is the decision for MSF's involvement and the level of involvement made?

We are active in more than 75 countries. According to the latest typology of our projects (in 2002) more than 480 projects were in action during that specific year. This total number is a quite consistent number and does not vary a lot throughout the years. More than 60% of these projects are in Africa while more than 20% of them are in Asia, the rest being in Central America and Europe .

Every year projects are closed and opened depending of the needs of the population we assist, and the political situation in the countries where we do intervene.

In 2002 more than 60% of our projects took place in either armed conflict or post conflict or unstable contexts. The decision of opening or closing a project is dependant on many factors. As a humanitarian organisation, there are three minimum conditions that must co-exist to satisfy the conditions of what is called, “Humanitarian Space”. These three conditions are:

The freedom of access and dialogue with the target population, without any interference by governments or other actors

The freedom to act independently – in evaluating, responding to, and communicating on, the nature and extent of the needs

The freedom to ensure that the aid physically reaches the target population.

When these conditions are co-existing, projects are opened in relation with the results of the medical needs as assessed by our teams in the field. MSF in general is not involved in long-term programs the core of our activities could be simply described as life-saving operations in emergency contexts.

In what way has MSF been involved with the displacement of the Sudanese refugees? Is this still considered to be the largest current humanitarian emergency in the world?

MSF has been assisting over 700,000 internally displaced people in the Darfur region in western Sudan , where a civil conflict is forcing civilians from their land and forcing them into large camps where they live under the threat of ongoing violence and disease. It is difficult to determine what is exactly the largest current humanitarian emergency in the world, however we can identify internally that our largest humanitarian operations are now in Sudan and the Democratic Republic of Congo, followed by our emergency response to the recent Asian tsunami. On this specific issue, MSF has published its Ten Most Underreported Humanitarian Emergencies for 2004, as follows:

Intense Grief and Fear in Northern Uganda

For 18 years, people in northern Uganda have endured a brutal conflict with consequences that are nearly invisible to the outside world. More than 1.6 million people – 80 percent of northern Uganda ’s entire population – have been displaced and now live in squalid conditions. Civilians have been attacked and killed by the Lord’s Resistance Army (LRA) in their villages, as well as in the camps where they have sought refuge.

No End in Sight to Devastating Conflict in Democratic Republic of Congo (DRC)

Civilians were once again besieged in the eastern DRC when fighting erupted in North Kivu this past December (2004). Nearly 150,000 people fled for their lives from Kayna, Kanyabayonga, and Kirumba just a few weeks after thousands of others fled fighting in the Mitwaba region. These were just the latest chapters in a decade-long war that has cost an estimated three million people their lives and reduced an already impoverished country’s limited infrastructure to ruins. Towns like Bunia, in Ituri province, still bear scars from last year’s fighting, and rape is widespread. Political divisions often erupt along ethnic lines, affecting entire areas of a country the size of western Europe, where many Congolese cannot meet even their most basic needs.

Civilians Caught in Colombia ’s Crossfire

Forgotten by much of the world, Colombia ’s enduring conflict continues to inflict great misery on civilians. More than three million people have been displaced within the country, usually to vast shantytowns on the outskirts of major cities, and violence is still the leading cause of death.

Tuberculosis Spiralling Out of Control

Tuberculosis (TB) kills one person every 15 seconds, thus claiming millions of lives every year even though it is a curable disease. While the risk of TB is relatively low in wealthy countries, the disease is making a comeback throughout the developing world: one-third of the world’s population is infected with the TB bacilli and eight million people annually develop active TB. Unfortunately, most TB is diagnosed by sputum microscopy, a diagnostic test developed in 1882, and the only available medicines for treatment were invented up to 60 years ago. TB treatment takes a minimum of six months and nearly two years for multi-drug resistant (MDR-TB) strains. The AIDS pandemic has led to an explosion of HIV/TB co-infection, as TB is the most common opportunistic infection for those living with HIV/AIDS. This further increases TB’s appalling human toll.

Somalia Shattered By Anarchy and Chaos

Fourteen years of violence have dramatically affected Somalia ’s population of nine million, with approximately two million people displaced or killed since civil war erupted in 1990 and close to five million people estimated to be without access to clean water or health care. The collapse of the health-care system along with most other state services, have hit women and children particularly hard: one in sixteen women die during childbirth; one in seven children die before their first birthday; and one in five children die before the age of five.

The Trauma of Ongoing War in Chechnya

A decade of intense conflict continues to devastate people in and around Chechnya . Despite repeated claims from officials that the situation is ‘normalising,’ Chechnya is far from peaceful and stable. Even so, since 2003, Russian and Ingush authorities have put considerable pressure on internally displaced people (IDPs) in Ingushetia to return to the war-ravaged region. By the end of 2004, only 45,000 people who fled the conflict, out of an original 260,000, remain in Ingushetia and are living in terrible conditions, while those pressured to return to Chechnya have been placed in “Temporary Accommodation Centres,” where conditions are not much better.

North Koreans Endure Massive Deprivation and Repression

A man-made cataclysm continues to rage in North Korea , where people struggle against violent repression and massive deprivation in a country that is almost entirely sealed-off from the outside world. In the late 1990s, an estimated two to three million people starved, and recent stories from refugees reveal that the food and health situation is still dire. Even though huge amounts of international assistance pour into the country, there is no way of knowing if it reaches those most in need and many suspect that the bulk of aid is simply diverted by the military regime. Economic reforms, introduced in July 2002, have exacerbated problems, resulting in runaway inflation that undermines people’s ability to afford basic food items.

Constant Threat of Hunger and Disease in Ethiopia

More than 10 percent of children do not survive their first year of life in Ethiopia . Scarce farmland in the over-populated arid highlands leaves approximately five million of Ethiopia ’s 69 million people to face chronic food shortages. Severe droughts in 1999 and 2001 compounded the situation. While some recent rains have provided a little respite, the lack of substantial rainfall since early 2003 has led to the deaths of an estimated 50 percent of people’s livestock.

The War is Over, But Liberians Still Live in Crisis

Intense fighting during the summer of 2003 in Liberia ’s capital, Monrovia , cost more than 2,000 people their lives. More than a year after this debilitating 15-year civil war ended, Liberians are still living in a state of crisis. Little of the country’s demolished infrastructure remains, leaving most people without basic services like water and sanitation. More than 300,000 people are still displaced within the country while 300,000 refugees wait to return from neighbouring countries. Health care, already scarce in the main cities, hardly exists at all in remote areas of the country. Today, there are only 30 Liberian physicians working in a country with more than three million people. In Bong County , MSF provides 7,000 consultations a month for 60,000 displaced people.

What is your view about the level of media coverage and international assistance that has been provided for the Sudanese refugees experiencing violence in Dafur? What would you like to have seen done for these people?

In 2003 there was little or no coverage of the humanitarian crisis unfolding in Darfur and last year there was a lot more coverage and media attention, following high level interest from the United Nations, European and North American actors. From the time when MSF first started working in Darfur in November 2003, we were desperate for the international community to respond to the crisis because it was well beyond our own means to handle the humanitarian situation, however since the increase of awareness throughout 2004, more aid has been allowed to flow to these people. The problem now in 2005 is that violence persists and the 1.5 million displaced Darfurians are too scared to return to their homes and villages, so it is becoming a protracted humanitarian crisis. This is even more difficult to overcome as the world and media become used to the images and stories coming from Darfur and other disasters and conflicts divert attention away from this ongoing crisis in Sudan .

How difficult is it to for MSF personnel to remain as an independent source of assistance in countries such as Iraq where there is a blatant disregard for humanitarian assistance? Has there been any situation when this independence has been compromised?

Remaining an independent humanitarian actor, is part of the fight of every day work now. Being able to maintain a “Humanitarian Space” in a context of war, is an incredible challenge for our teams at field level.

Afghanistan is a sad example of this on going challenge. The ongoing co-optation of humanitarian aid by coalition forces that blur the lines between humanitarian and military action has largely contributed to a deadly confusion. The killing of our team in Badghis Province in Afghanistan in June 2004 is the result of this confusion.

Our field volunteers and operational centre have to take their decisions based on the analysis of the risks for our team and the benefits for our patients to stay or to leave from a given country. In such circumstances like in Afghanistan , there is no room for compromise, the only choice is to withdraw and leave the country. This is what we did after 25 years of activity in Afghanistan . We took the decision of not staying in Iraq based on similar reasons.

What has been the most difficult decision you have had to make during your involvement with MSF?

It’s now 10 years that I’m directly involve with MSF and the most difficult decisions I have made are all in relation to the “borders” that governments, rebels and coalition forces set up between us and the victims we want to provide humanitarian aid to. One of the most difficult decisions was our withdrawal from Madagascar where I was Head of Mission. Madagascar is one of the poorest countries and for the first time since the beginning of the last century, this island was confronted with a cholera outbreak. The health system was not ready to deal with such a big outbreak that had already claimed hundreds of lives. We had already been working in this country for four years when the epidemic started to claim its first victims. Despite all the efforts we put in place and all the negotiations we went through, the Ministry of Health did not allow us to respond to this deadly emergency. After days of negotiations with different levels of the government, we had to decide to leave. It was not acceptable for us to stay nearby the victims of this emergency, having all the means to save their lives and not being authorised to work.

How do you cope with having to regularly deal with global situations of extreme despair and hopelessness where one does not have the power to change the underlying causes but only work with those whom it has severely affected?

As a medical aid organisation we tend to focus on our objective which is to improve the situation for people living in danger, to make things better for individuals in times when their life is most at risk. By focusing on individuals and their plight we see the improvement that we can make and the affect we have on these people, one at a time.

It can become frustrating at times when you ponder all the world’s problems but as I said, we can make a considerable difference in the lives of some of the most destitute victims of natural and man-made disasters, when they need it most, and when there is no other assistance available.